胆结石预防、诊疗的研究进展
Research Progress in the Prevention, Diagnosis and Treatment of Gallstones
摘要: 胆结石是一种多因素影响的良性疾病,其具体发病机制尚未确定,但与其相关的影响因素已被相继揭晓。目前对于胆结石的预防和诊治方法多种多样,本文通过检索相关文献,就胆结石的预防及各种治疗方式的优劣作一综述,为预防和治疗胆结石提供最优选择。
Abstract: Gallstones are a benign disease with multifactorial influences, and its specific pathogenesis has not been determined, but the factors associated with it have been revealed. At present, there are vari-ous methods for the prevention and diagnosis and treatment of gallstones, and this article reviews the prevention of gallstones and the advantages and disadvantages of various treatment methods by searching relevant literature, so as to provide the best choice for the prevention and treatment of gallstones.
文章引用:赵立军, 渠海. 胆结石预防、诊疗的研究进展[J]. 临床医学进展, 2023, 13(6): 9309-9319. https://doi.org/10.12677/ACM.2023.1361303

1. 研究背景

胆结石病为全世界最常见的消化道系统良性疾病,在全球发病约为10%左右,在某些地区的发病率甚至要远远高于这个数据,如欧美地区其发病率高达20%,特殊人群中胆囊结石的发病率甚至可达60% [1] 。大多数患者不会出现症状:高达50%~70%的患者可能永远不会经历胆道疼痛或并发症,如:急性胆囊炎,胆管炎或胰腺炎 [2] 。结石对胆道系统的长期刺激有可能导致胆道系统恶性病变的可能,Randi等人总结了10项有关评估良性胆囊疾病(主要是胆结石)病史与胆囊癌风险之间的关联的研究报告,得出胆囊结石病史是胆囊癌最强的危险因素,汇总相对风险(RR)为4.9 [3] [4] 。高发病率的胆结石病对全人类的经济及生活带来严重的影响。近几十年来,由于人们对胆结石的病理生理机制越来越深入,以及内镜和外科手术的显著技术发展,胆结石患者的跨学科诊疗取得了非常大的进步。相比之下,这种常见疾病的初级预防仍处于初级阶段。本文通过检索国内外相关文献,就胆结石发病诱因、预防、诊断及治疗方面作一综述,以期为临床医师治疗胆结石时提供帮助,使胆结石患者在治疗过程中受益最大化。

2. 胆结石的危险因素及预防措施

据多项病例对照研究比较了胆结石患者与无胆结石患者,表明胆结石形成是多因素的,Song等人2016年至2017年间在上海进行了一项基于人群的横断面研究,使用三阶段分层抽样策略,招募了来自4009个地区的1753名参与者,结果显示年龄 > 40岁、腰高比 > 0.5、家族史、甲状腺疾病、高血压、糖尿病等均是胆结石的高危因素 [5] [6] 。一些因素,如种族、遗传、年龄增长和女性性别都是不可能更改,而其他因素,如饮食、体力活动、快速减肥和肥胖等是可以通过外界干预的 [7] 。

2.1. 种族及遗传

民族和种族是一个重要的危险因素。北美和南美的土著民族胆结石病患病率最高,研究表明,超过70%的40岁以上妇女患有胆结石 [8] [9] 。在非洲黑人中,情况正好相反,5%的人患有胆结石 [10] [11] 。胆结石在白人和亚洲人的患病率介于两者之间 [12] [13] 。这种患病率差异的原因尚不清楚,遗传可能起着很大的作用,但也有环境因素的影响,如:饮食,素食者患胆结石的风险似乎较小 [14] [15] [16] 。Hemminki等人通过标准化发病率(SIRs)计算为观察到的病例数与预期病例数的比率,其结果显示有胆结石家族史的患者发生胆结石并发症的风险几乎是没有家族史患者的2倍,当父母和兄弟姐妹都被诊断出患有胆结石疾病时,SIRs最高(男性和女性合计为2.58),而只有父母一方时为1.62,只有兄弟姐妹被诊断为1.75。当父母双方都受到影响时,SIR为2.44,并且患有胆结石的亲属越多,风险就越高 [17] 。

2.2. 性别及年龄

女性患胆结石的风险明显高于男性 [18] [19] 。这种可能性在青春期就开始增加,并且直到绝经期之后,而在老年时期,男性和女性胆结石的发病率相似。避孕药的使用和怀孕与患胆石症的风险增加有关,因为血液中的黄体酮和雌激素水平较高 [17] 。这可能与黄体酮能减缓胆囊的运动,雌激素促进胆固醇阻滞有关。因此,胆结石病在怀孕期间很常见,也是孕妇住院的最常见原因。据有关的研究表明,孕妇最常患胆汁淤积症,而更严重的胆结石并发症在怀孕期间不太常见 [20] [21] 。胆结石的发生率随着年龄的增长而增加,在40岁后明显增加,在老年人中的发病率可增加4至10倍 [22] 。结石类型也随着年龄的增长而变化:最初主要由胆固醇组成(这与胆固醇分泌增加和胆汁饱和有关),但在晚年往往是黑色色素结石。此外,症状和并发症也随着年龄的增长而增加,导致更频繁的胆囊切除术 [23] 。

2.3. 肥胖及快速减肥

超重的人更容易患胆石症,超重人群的患病风险是正常人群2倍,即体重指数(BMI)高于25,BMI高于45时风险是7倍 [19] [24] 。超重的人会形成更多的胆固醇,并将更多的胆固醇分泌到胆汁中,然后胆汁会变得过度饱和,这会增加胆结石形成的风险 [25] 。低高密度脂蛋白胆固醇水平是胆结石形成的危险因素,以及高水平的甘油三酯,导致胆囊收缩减少 [26] [27] 。出于同样的原因,糖尿病会增加患胆结石的风险。因此,超重和胰岛素抵抗增加的代谢综合征是一个危险因素 [28] 。近年来日益严重的肥胖问题导致胆结石及其并发症的发病率增加 [29] 。在短时间内过度减肥可能会增加患胆结石的风险。在节食期间,身体的脂肪储存减少,胆固醇循环并增加胆汁过度饱和的风险,胆囊排空也因食物摄入量减少而受损 [30] 。几乎一半接受过代谢综合征(如袖状胃切除手术)手术的患者会出现胆结石,胃绕道手术的激素分泌改变与体重减轻有关,影响胆囊收缩、肝肠循环变化和胆汁流动惯性可能增加 [31] 。尽管这些手术患者发生胆结石的风险增加,但与一般人群相比,胆结石并发症的风险似乎并未增加。据相关研究表明 [32] ,与一般人群相比,接受胃绕道手术的患者更有可能接受胆囊切除术,无论是在胃绕道手术之前,还是在胃绕道手术后6~36个月 [33] 。根据最近的一项研究表明,5%的患者在胃绕道手术后接受胆囊切除术 [34] 。在长期接受静脉营养的个体中,近40%的人在不到两年的时间内发现患有胆结石 [32] 。那些很少或根本不口服和肠外营养的人特别危险,因为激素分泌减少和肠道蠕动降低,进一步减少胆囊收缩,增加患胆结石的风险 [35] 。

2.4. 饮食及生活方式

据观察,典型的西式饮食会增加胆结石病的可能性,快餐、西餐、果糖、低纤维、反式脂肪、低维生素C似乎都会增加胆石症的风险 [36] 。相比之下,脂肪、鱼油、n-3多不饱和脂肪酸、咖啡、蔬菜、素食、酒精都可降低胆结石风险 [37] 。这种饮食变化也可能是亚洲国家从色素结石到胆固醇结石的转变的原因 [38] 。体力活动的减少会增加患胆石病的风险,而增加体力活动有助于预防胆石症,这与其在减肥中的作用无关,增加耐力运动(每周30次,每次5分钟)可避免男性出现有症状的胆结石 [39] 。

2.5. 基础疾病

代谢综合征、血脂异常、糖尿病和胰岛素抵抗/高胰岛素血症经常与胆结石病同时发生。Ruhl和Everhart报告表明,在患有2型糖尿病的胰岛素抵抗受试者中,胆结石病的患病率高出2~3倍 [40] 。此外,肝脏胆固醇分泌增加、胆汁过饱和度和胆囊运动障碍加剧了代谢综合征的状况,为胆结石的发展提供了理想的环境 [41] 。慢性丙型肝炎病毒(HCV)感染也可能增加患胆结石的风险。在对456名参与者的美国国家健康和营养检查调查中,发现与HCV阴性男性相比,患有HCV感染的男性患胆结石和由此产生的胆囊切除术的风险增加 [42] 。虽然在这项研究中没有报告女性的HCV关联,但其他研究发现,两种性别中HCV的存在都与胆结石风险增加有关。在HCV患者中,Acalovschi等人报告中心性肥胖和肝脂肪变性是重要的危险因素,这两者都与胰岛素抵抗有关 [43] 。胰岛素抵抗,由于其增加胆汁胆固醇饱和度的能力,已被建议作为胆结石发展的因果关系 [44] 。肝硬化和克罗恩病也被证实胆结石的危险因素,特别是黑色色素胆结石 [45] 。

综上所述,胆石症是一种常见的多因素疾病。一些因素是我们无法改变的,例如:种族、遗传、年龄、性别,但在肥胖、快速减肥、饮食、生活方式、基础疾病等方面的因素是可以通过人为干预得到一定的预防效果。饮食习惯与胆结石病相关的因素已经得到了广泛的研究,在预防胆结石形成上开辟了道路,特别是在高风险人群中。通过充足的能量摄入和生活方式的干预来维持理想的体重,在超重和肥胖个体中适当减轻体重,对于减重手术的患者,术后使用UDCA 6个月是一种有效的预防措施,可减少减肥手术后胆结石的形成 [46] ;对于有基础疾病的高危人群,积极治疗基础疾病,可能会显著降低高危人群患胆结石病的风险。尽管已经完成了大量的研究工作来确定胆石症的危险因素,但胆结石的危险因素仍需进一步研究证实。胆结石患病率因地域和种族而异,因此,胆结石的预防措施也应因地而异。了解胆结石病的病理学及高危因素可以帮助医生为那些被诊断为有症状的胆结石的患者提供资源和教育,也可能有助于预防胆石症。

3. 胆结石的诊断

上腹部或右上腹部绞痛、黄疸和发热是胆囊和胆管疾病的主要症状。如果患者清楚地回忆起上腹部或右上腹部持续超过15分钟的疼痛发作,则可以认为存在胆绞痛。疼痛可能放射到右肩或背部,并经常伴有恶心,有时伴有呕吐。然而,关于胆道症状的特异性尚无共识,有症状的胆结石病可能伴随多种症状。有症状胆结石的年并发症发生率为1%~3%,但无症状结石患者的年并发症发生率仅为0.1%~0.3% [47] 。胆囊中存在多发结石会增加症状性胆总管结石或急性胆囊炎的风险。

胆石症的存在与否还应通过经皮超声检查来证明。超声检查具有无创的优势,其敏感性为 > 95%,特异性几乎为100%,是胆囊结石的首选检查方法 [48] 。检查的目的是明确胆囊内结石位置、大小及数目。在英国国家卫生与临床技术优化研究所(National institute for Health and Care Excellence, NICE)建议疑似胆结石患者应接受腹部超声检查和血液检查,包括确定肝功能指标的检查 [49] 。

急性胆囊炎是胆石病最常见的并发症,并且在90%的病例中由永久或暂时阻塞胆囊管引起 [50] [51] 。这种机械阻塞伴随着由溶血卵磷脂释放引起的化学炎症,在一些患者中,还可能由于随后的细菌炎症引起,通常情况下三个因素会同时存在。急性胆囊炎的诊断基于以下四种症状中的三种:右侧上腹痛、墨菲征阳性、白细胞增多和发热,除此之外还应存在胆石症或胆囊炎的超声诊断。急性胆囊炎的其他超声诊断可能还包括胆囊周围积液和胆囊壁厚度增加等。如果超声检查结果不明确,或者怀疑有并发症,计算机断层扫描(CT)和磁共振成像(MRI)可以提供有用的信息 [52] [53] [54] ,经皮超声检查还可同时评估肝内和肝外胆管 [55] [56] 。使用这些诊断标准,可以清晰地诊断急性胆囊炎 [57] 。

当临床检查或患者病史提示怀疑胆总管结石时,还应确定总胆红素、γ-谷氨酰转移酶(γ-GT)、碱性磷酸酶(AP)、丙氨酸氨基转移酶/天冬氨酸氨基转移酶 (ALT/AST)和脂肪酶,并系统地进行腹部超声检查。临床症状、实验室检查和超声检查结果可将胆石症患者同时伴有胆总管结石的风险分为高、中或低三个级别。只有在胆总管结石存在的可能性很高的患者中,才应进行具有治疗目的的内窥镜逆行胰胆管造影术(Endoscopic retrograde cholangiopancreatography, ERCP)。如果可能性为中等或低等,建议进行内镜超声检查或磁共振胰胆管造影(Magnetic resonance cholangiopancreatography, MRCP)以确定是否需要进行ERCP [58] 。

在胆总管结石伴或不伴有急性胆管炎通过超声检查确诊情况下,还需要进行ERCP,除了可达到诊断胆管结石的目的外,同时还可进行治疗干预,即胆道括约肌切开术和取石术。如果强烈怀疑胆总管结石但尚未通过影像学检查确诊,则首选ERCP是合理的,因为其敏感性和特异性均超过90%。

内镜超声检查对检测胆总管结石的灵敏度最高。在经验丰富的检查者手中,内窥镜检查具有几乎100%的灵敏度和超过93%的特异性,用于诊断和排除胆总管中的结石 [50] [59] 。

MRCP对胆总管结石也具有高敏感性和特异性,但与内超声检查相比,其对小结石(<5 mm)的检测有限 [58] 。尽管两种方法的直接比较显示出相似的特异性,但内镜超声检查的灵敏度明显优越(97%/87%) [59] 。

如果临床怀疑急性胆管炎,临床症状的记录应伴随着炎症指标的测定。这包括感染指标,如:白细胞、C反应蛋白(CRP)和胆汁淤积指数(胆红素、碱性磷酸酶、γ-GT和转氨酶)。此外,还应进行胆管腹部超声检查,以检测或排除胆管增宽(>7 mm)、结石或任何其他引流障碍。如果临床高度怀疑急性胆管炎,但超声检查未显示胆管增宽、结石或任何其他类型的阻塞,则应进行内镜超声检查或MRCP [60] 。

急性胰腺炎合并胆总管结石、胆管闭塞或胆管炎患者的主要检查手段应采用具有治疗目的ERCP。如果病因尚未确定,则首选是内镜超声检查或MRCP。对于胆道疾病,只要有内镜治疗指征的,则首选ERCP。

4. 胆结石的治疗

4.1. 胆绞痛的治疗

急性胆绞痛的治疗主要包括使用非甾体抗炎药(NSAID)或麻醉止痛药控制疼痛。非甾体抗炎药是大多数患者的首选,因为它们同样有效,不良反应更少。一项针对324名静脉注射酮咯酸或哌替啶患者的随机对照试验发现,这两种药物在缓解疼痛方面同样有效,但接受非甾体抗炎药的患者不良反应较少 [61] 。

控制疼痛的另一种选择是解痉药(例如东莨菪碱),它被认为可以放松和缓解胆囊痉挛。然而,比较研究表明,非甾体抗炎药提供更快、更有效的疼痛缓解。作为胆绞痛保守治疗的一部分,患者应禁食,并避免释放内源性胆囊收缩素 [62] 。

4.2. 药物治疗

胆结石的药物治疗主要有以下几种。

1) 溶石类药物的代表药物之一是熊去氧胆酸(Ursodeoxycholic acid, UDCA)。UDCA治疗可以减少胆汁脂质的过氧化。此外,UDCA还降低了胆汁中粘蛋白的浓度,这种作用是由胆囊胆汁粘蛋白促分泌活性降低介导的。UDCA的这些作用有助于改变胆固醇结石患者的胆囊中胆汁成分,以达到溶解结石的目的。UDCA的治疗效果得到了美国食品药品监督管理局的肯定。相关文献报道,UDCA还具有抗炎、抗凋亡的作用 [63] 。但溶石所需时间较长,其适用的病例也较为有限,溶石治疗也因其受到很大的限制 [64] [65] 。

2) 他汀类药物是3-羟基-3-甲基戊二酰辅酶A还原酶的抑制剂,还原酶是肝脏胆固醇生物合成的限速酶。目前,用于治疗胆囊结石他汀类药物主要包括:洛伐他汀、辛伐他汀、普伐他汀、氟伐他汀等。他汀类药物可以通过抑制合成胆固醇的限速酶降低胆汁中胆固醇的浓度,延缓胆囊结石的形成,达到降低胆囊结石发病率的目的 [66] 。国外的一项流行病学研究表明,长期口服他汀类药物可降低症状性胆结石病的风险,且长期使用他汀类药物的患者发生胆结石疾病后进行胆囊切除术的风险降低 [67] [68] 。他汀类药物和熊去氧胆酸联合用药在胆固醇胆结石溶解方面要比单独使用熊去氧胆酸治疗更有效 [69] 。他汀类药物和口服胆盐的作用与降低胆汁中胆固醇的过饱和率有关,但它们尚未被证明对所谓的壁膜或粘膜因素(胆囊粘蛋白,胆红酸钙,胆囊动力障碍)有效,这些因素都是胆固醇(和黑色色素)结石形成和复发的重要因素。他汀类药物在防治胆囊结石方面还存在争议,仍需进一步的深入研究。

3) 脂感应核受体在人体中的主要作用是维持脂质代谢平衡,脂感应核受体相关药物主要通过影响肝X受体(liver X receptor, LXR)和法尼酯衍生物X受体(farnesoid X receptor, FXR)来调控胆固醇的合成与分泌,这种机制可能对胆囊结石的预防起到一定的作用,其具体机制还需相关研究证实,关于脂感应核受体的相关药物的安全性和有效性,还需进一步的临床试验研究证实 [70] [71] [72] 。

4) 胆固醇吸收抑制剂依泽替米贝可以通过抑制尼曼–匹克C1样1蛋白(NPC1L1)来降低血浆中胆固醇浓度 [73] 。大量的研究表明其在高胆固醇血症方面的治疗是安全有效的,但在降低胆囊结石的风险上的研究比较少,是否可以用于高风险人群的胆囊结石预防还需大量的循证医学研究 [74] [75] 。

5) 灌注溶石疗法是指直接将药物灌入胆囊内,常用的药物有二甲基亚砜胺、1%依地酸钠、白芨加甲基叔丁醚,灌注药物可能导致胆囊内膜受损,继而发生胆囊炎、胰腺炎、胆管炎、溶血等并发症及不良反应,目前临床已较少采用 [76] 。

6) 中医疗法主要包括:中药、中成药内服及针灸等疗法,主要以排石、溶石为目的,但排石具有胆总管梗阻及梗阻性胰腺炎的风险。其在保留尚存正常功能的胆囊和消化系统内环境中有着一定作用,还可以改善胆囊切除术后的肠道菌群失调、术后腹泻、结石复发等问题,因缺乏大量的循证医学证据,目前中药疗法在临床上未得到广泛的推广和使用 [77] 。

4.3. 手术治疗

4.3.1. 单纯胆囊结石的治疗

1) 传统开腹胆囊切除术

自1882年Langenbuch完成了世界第1例胆囊切除术(Open Cholecystectpmy, OC)以来,被称为胆囊结石治疗的金标准 [78] 。但OC手术对患者创伤大,术中出血量多,术后并发症发生率多,延长患者术后恢复时间,术后腹部还留有手术瘢痕。

2) 腹腔镜胆囊切除术

随着腹腔镜技术的发展及普及,腹腔镜胆囊切除术(Lparoscapic Clmlecysleclmny, LC)现已成为治疗胆囊结石的首选方法。LC与OC相比较,其具有手术创伤小、术后并发症发生率低、术后患者恢复快,明显缩短患者住院时间的优势 [79] 。LC术后患者无较大的手术瘢痕,随着微创理念的发展,LC也由以往的“四孔法”发展到了“三孔法”和“两孔法”。

3) 胆囊造瘘取石术

胆囊造瘘术是早期的保胆手术主要术式,该术式是通过切开胆囊取出石头,未对胆囊进行摘除。因为其取石是在肉眼下进行,存在结石残留的情况。据相关研究报道,其术后结石复发率可达40%,目前该术式只适用于对于危重胆囊炎、胆囊切除禁忌症的患者的急救方式 [80] 。经过近些年的研究,其术式得到改进,即经皮经肝肝胆囊穿刺造瘘术,具有比胆囊造瘘术创伤小等优势,但是其不能去除胆囊内的结石,只能进行胆汁引流,缓解胆囊内压力,以减轻症状,为接受胆囊切除术的患者争取充足的术前准备时间。

4) 内镜微创保胆取石术

随着近年来科学技术的进步和发展,对胆囊切除术后并发症的探索,人们越来越重视胆囊的功能。我国学者张宝善 [81] 提出了内镜微创保胆取石术,该术式比以往的保胆取石术创伤小,结石的复发率得到了很好的控制,据研究统计结石的复发率低于10% [82] 。中国医师协会内镜医师分会内镜微创保胆专业委员会先后制定了有关内镜微创保胆取术的相关指南,以便该术式在临床上的规范应用 [83] 。研究表明,该术式可以有效的减低患者术后并发症的出现,但其术后结石复发一直存在着争议,其治疗效果还需大量的临床研究进行证实。目前还有经自然腔道的保胆取石术的研究报道,但其术后可能导致腹腔感染的风险,并未得到大部分学者的关注 [84] 。

4.3.2. 胆囊结石合并胆总管结石的手术治疗

1) 胆道镜手术

对于和并胆总管结石的胆囊结石的手术方式为在胆囊切除术的基础上运用胆道镜进行胆道探查、取石加T管引流术。主要术式为:① 开腹胆囊切除术联合胆道镜胆总管切开取石加T管引流术,术式操作简单,但对患者创伤大,术后患者恢复时间长等缺点。② 腹腔镜胆囊切除术联合胆道镜胆总管切开取石加T管引流术,此术式对手术设备及术者对腹腔镜技术的熟练度要求较高,与开腹比较,其拥有创伤小,术后患者恢复快的等优势。③ 腹腔镜下胆囊切除联合经胆囊管胆总管探查取石术,该术式与前两种手术方式的不同之处为通过胆囊管进入胆道镜,无胆总管切开,保证胆总管完整性,有效降低了术后胆总管狭窄的风险 [85] 。

2) 十二指肠镜手术

十二指肠镜手术主要包括内镜括约肌切开术(endoscopic sphincterotomy, EST)、ERCP,EST的优势主要在于可以取出胆总管较大结石,但其破坏了Oddi括约肌的功能,术后并发症较多。ERCP保留了Oddi括约肌的功能,其在取石上受到了限制。内镜下十二指肠乳头球囊扩张术(endoscopic papillary balloon dilatation, EPBD)的应用,使其在结石取出率上得到了一定的改善,还可以在ERCP下行鼻胆管引流术 (endoscopic nasal biliary drainage, ENBD),进行胆汁引流 [86] 。

3) 三镜联合治疗

三镜联合治疗即腹腔镜、胆道镜和十二指肠镜三镜联合治疗胆囊结石合并胆总管结石。其优点在于通过鼻胆管引流来降低胆道内压力和支撑胆道,避免术后患者长期携带T管,同时减少了一期缝合胆总管术后出现胆漏及胆管狭窄的风险。其缺点在于对手术适应症要求严格,比如:无解剖变异的胆道系统,胆囊三角区无严重粘连,术前能成功进行ENBD引流,术中探查胆总管下端无狭窄或Oddi括约肌无水肿等条件 [87] 。

5. 总结

综上所诉,胆结石的发病机制尚未明确,且影响因素众多,包括可变因素和不可变因素,通过分析不可变因素可将普通人群分为高危人群和低危人群,而对于可变因素,可通过认为干预进行预防胆结石的形成,如改变饮食和生活习惯,进行适当的减肥,减肥术后服用药物进行预防等措施。胆结石的诊断主要通过其临床症状,及相应的影像学证据,超声是胆囊结石的首选检查,对于怀疑合并胆总管结石的患者可首先进行CT、MRCP等检查。目前临床上针对胆结石的治疗方式多种多样,各有优劣。药物溶石治疗其疗效时间长,效果不明显,易结石复发。胆囊切除术仍是胆囊结石的首先治疗方式,术后仍有一定的术后并发症,内镜微创保胆取石术虽在术后并发症上有所改善,为有强烈保胆要求的患者提供了机会,但其术后结石复发一直使其存在争议。对于胆囊结石和并胆管结石的手术治疗仍是胆囊切除术加胆道镜手术为主,其腹腔镜下胆囊切除术加胆道镜胆总管切开取石T管引流术为目前的首选术式,其创伤较开腹小,适用于大部分患者,手术适应症广。对于患者应该采取何种治疗方式,临床医生应该综合评估患者一般情况,包括其年龄、性别、结石位置、大小、数量、胆总管情况等,选择适合患者的治疗方式,体现个体化医疗理念,使患者在治疗过程中收益最大。

NOTES

*通讯作者。

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